Healthcare Provider Details

I. General information

NPI: 1801954318
Provider Name (Legal Business Name): BRUCE E DWELLY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4944 SUNRISE BLVD STE A
FAIR OAKS CA
95628
US

IV. Provider business mailing address

4944 SUNRISE BLVD STE A
FAIR OAKS CA
95628
US

V. Phone/Fax

Practice location:
  • Phone: 916-863-6288
  • Fax: 916-863-1144
Mailing address:
  • Phone: 916-863-6288
  • Fax: 916-863-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0201710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: